Skip to main content

Penile Prosthesis with Adjunctive Straightening

For patients with Peyronie's disease plus erectile dysfunction refractory to medical therapy — or with severe deformity and borderline EF — the inflatable penile prosthesis (IPP) addresses both problems simultaneously. The device replaces native erectile function and serves as a rigid internal splint against which the curved penis is straightened at the time of implantation. The contemporary multicenter data are remarkable: 82% of PD-IPP cases require some adjunctive straightening maneuver beyond simple prosthesis placement, and the adjunctive ladder — modeling → plication → grafting — is now considered core skill for the prosthetic urologist treating PD.[1]

This article covers the adjunctive ladder, prosthesis selection for PD, and the 2026 data on extended corporal dilation as a way to reduce modeling requirements.

Indications​

  • PD + ED refractory to oral medications, VED, and ICI
  • PD + penile deformity sufficient to prevent coitus despite adequate natural erectile function — when the deformity itself is the primary barrier and medical management of EF is not the issue
  • Patient preference for a definitive, one-operation solution that addresses both EF and deformity[2][3]

Prosthesis Selection​

Inflatable IPP is strongly preferred over malleable/semi-rigid for PD:[2][4]

  • Allows manual modeling (the first-line adjunctive maneuver) — this is not effective with semi-rigid devices
  • Enables full inflation for intraoperative assessment of residual curvature
  • Allows post-operative home modeling in patients with residual curvature
  • Produces superior patient satisfaction scores

Within inflatable devices:

  • AMS 700 CX — workhorse; Momentary Squeeze pump; most commonly used for PD
  • Coloplast Titan OTR / Touch — comparable outcomes
  • AMS 700 LGX — often avoided in PD because longitudinal expansion can worsen a hinge deformity. Surgeon-dependent; some experienced implanters use LGX in PD without issue.

See penile implants — implant models for the full device database.

Approach​

The subcoronal approach is preferred when significant tunical work (grafting) is anticipated at implant, as it provides direct visualization of the entire shaft. Penoscrotal is acceptable for milder deformity requiring only modeling. See penile implants — surgical approaches.

The Adjunctive Ladder​

From the Hammad 2025 J Sex Med multicenter study of 499 PD patients undergoing IPP:[1]

Adjunctive techniqueFrequencyMedian curvature correction
IPP alone (no adjunct)17.6%N/A
Manual modeling (± scratch technique)74.7%26° [IQR 20–39.5°]
Concurrent tunical plication4.8%40° [28.8–41.2°]
Concurrent grafting2.0%55° [48.8–73.8°] (highest but least-used)

The ladder is applied intraoperatively in sequence: implant, inflate, assess residual curvature, model, reassess, escalate if needed.

Step 1 — IPP Placement​

Standard corporotomy, dilation, and cylinder placement. The Katlowitz 2026 J Sex Med data support extended corporal dilation (ECD) — Hegar dilation ≥14 mm — as a way to reduce the need for intraoperative adjunctive maneuvers in PD cases (P<0.05 for both residual curvature and adjunctive maneuver need).[5] The mechanism: ECD mechanically disrupts septal and tunical fibrosis during dilation, giving the cylinder more room to straighten the corpus.

Technique: After standard Dilamezinsert dilation, pass Hegar dilators serially up to 14 mm (or higher, surgeon preference) before cylinder placement.

Step 2 — Assess Residual Curvature​

Device fully inflated; goniometer measurement in multiple planes. If curvature is <15–20°, no adjunctive maneuver is needed. If >20°, proceed to modeling.

Step 3 — Manual Modeling​

See manual modeling for full Wilson-technique and Lucas optimal-modeling details.

Summary: With the device fully inflated, the penis is forcibly bent in the direction opposite to the residual curvature, in 90-second intervals, with sustained pressure on the glans to prevent urethral injury. Reassess after each cycle. Most residual curvature resolves with 3–4 modeling cycles.

If curvature resolves → closure. If curvature persists >30° after adequate modeling → escalate.

The scratch technique variant​

Some surgeons combine modeling with endocavernosal plaque disruption — "scratching" or sharply disrupting the plaque from inside the corpus through the corporotomy before cylinder placement. See scratch technique. Endocavernosal approaches avoid degloving and NVB mobilization while achieving comparable or better straightening in selected cases.

Step 4 — Concurrent Tunical Plication​

Used in ~5% of cases.[1][6]

Technique:

  • Permanent braided suture placed on the convex side of the penis, tying together the tunica at the point of residual curvature
  • Can be placed before or after cylinder deployment:
    • Pre-cylinder plication: avoids inadvertent cylinder damage from suture needle; allows tension adjustment under vision before device occupies the corpus
    • Post-cylinder plication: permits final assessment of where plication is actually needed after the cylinder is in place; higher risk of cylinder puncture if the needle is not carefully controlled

Outcomes: median 40° additional curvature correction beyond modeling alone.

Chung / Blecher perspective​

Concurrent plication at IPP is a defined technique — not a fallback. The Chung/Blecher 2023 paper frames it as a planned maneuver for patients with curvature 30–60° where modeling alone is unlikely to achieve straightening.[6]

Step 5 — Concurrent Grafting (PICS Technique)​

For severe residual curvature (≥60°) or complex deformity persisting after modeling and plication, plaque incision + grafting over the implanted cylinders — the PICS (Penile Implant with Collagen Sealing) technique — is the most aggressive adjunct. Used in ~2% of PD-IPP cases.[1][7]

PICS technique (Falcone, Hatzichristodoulou)​

Steps:[7][8]

  1. Complete IPP placement with cylinders in place
  2. Full device inflation
  3. Relaxing tunical incision over the concave-side plaque, performed cautiously to avoid cylinder perforation
  4. Collagen fleece (TachoSil) applied over the tunical defect with gentle pressure (3–5 min)
  5. No suture fixation required
  6. Confirm straightening; closure

Outcomes (Falcone multicenter study, 37 complex-PD patients):[7]

  • Median preoperative curvature: 75° (IQR 65–77°)
  • Median residual curvature after IPP alone: 60° (IQR 50–70°)
  • Complete straightness after PICS: 84%
  • Residual curvature <20° in remaining cases
  • No cylinder injury reported

Outcomes for complex PD with severe shortening​

Fernández-Pascual 2019 series of 43 complex-PD patients with severe shortening treated with IPP + multiple corporeal incisions + collagen fleece grafting:[9]

  • Mean postsurgical length gain: 2.5 cm (range 1–5 cm)
  • Average operative time: 86.7 min (IPP) / 71.6 min (malleable)
  • No glans ischemia despite extensive work
  • Hematoma/bruising: 23.2%
  • Overall satisfaction: 89.7% would recommend surgery
  • Satisfaction with straightness: 94.9%; with length: 82.1%

Graft choice for IPP + grafting​

Hemostatic patches (TachoSil / collagen fleece) vs. pericardium allograft — Farrell 2019 randomized data from 33 patients:[10]

  • Operative time: shorter with hemostatic patches (122 vs 166 min, P=.01)
  • Residual curvature >20°: 16.7% (patch) vs 13.3% (pericardium), not significantly different
  • Penetrative intercourse: 94.4% vs 93.3%, comparable
  • No complications attributable to graft material
  • No IPP herniation through tunical defect in either group

Bottom line: collagen fleece is at least equivalent to pericardium for IPP-plus-grafting and offers faster operative time.

Long-Term Outcomes​

Straightening​

  • >80% complete straightening across all studies reviewed in the AUA guideline
  • The Hammad 2025 data confirm this across modeling, plication, and grafting — all produce robust straightening in the contexts where they are appropriate[1]

Satisfaction​

Nuanced picture from Gamidov 2021 long-term analysis:[11]

  • 40.6% completely satisfied with erections
  • 57.6% completely satisfied with penile appearance
  • Only 29.5% completely satisfied with both appearance and erectile function

Predictors of satisfaction with EF:[11]

  • Preoperative IIEF-EF score (OR 1.67 per point)
  • Cadaveric pericardium graft (OR 61.4)
  • Saphenous vein graft (OR 8.5)
  • Tunica albuginea plication (OR 5.6)

Predictors of satisfaction with appearance:

  • Higher curvature severity → lower satisfaction (OR 0.93 per 5°)
  • Tunica plication → lower satisfaction (OR 0.12) — reflects length loss from concurrent plication

Complications​

  • Infection 1–2.7% — not elevated over IPP-alone rates
  • Mechanical failure — low with modern devices
  • Hematoma 16–24%
  • Transient fever ~8%
  • Residual curvature >20%: 8–16%
  • No correlation between surgical complexity (number of adjunctive maneuvers) and infection/revision rates or satisfaction[1] — an important finding that supports aggressive correction

Intraoperative Decision Algorithm​

IPP placed, fully inflated, residual curvature measured
         |
         v
   Residual &lt; 15°     →   Closure
         |
   Residual 15-30°    →   Manual modeling (Step 3)
         |
   Residual 30-45°    →   Concurrent plication (Step 4)
         |
   Residual > 45°     →   PICS / grafting (Step 5)
     or complex
     deformity

The decision is sequential and graded: attempt the least-invasive maneuver first and escalate only when needed.

Counseling​

  • Both problems are addressed in one operation — the main appeal
  • Manual modeling is expected in 75% of PD-IPP cases — patients should understand this is not a complication but a planned maneuver
  • Plication or grafting may be added for severe curvature — increases operative time but not infection risk
  • Length gain is possible with PICS/grafting in severe cases (1–5 cm reported)
  • Postoperative home modeling or vacuum therapy may be prescribed for residual curvature — compliance matters
  • Satisfaction with both appearance and EF is achieved in only 30% of patients — set this expectation honestly
  • Irreversibility — as with any IPP, natural erections end

See Also​

References​

1. Hammad MAM, Barham DW, Simhan J, et al. A multicenter evaluation of penile curvature correction in men with Peyronie's disease undergoing inflatable penile prosthesis placement. J Sex Med. 2025;22(2):349–355. doi:10.1093/jsxmed/qdae192

2. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's disease: AUA guideline. J Urol. 2015;194(3):745–753. doi:10.1016/j.juro.2015.05.098

3. Ziegelmann MJ, Farrell MR, Levine LA. Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review. Asian J Androl. 2020;22(1):51–59. doi:10.4103/aja.aja_81_19

4. Berookhim BM, Karpman E, Carrion R. Adjuvant maneuvers for residual curvature correction during penile prosthesis implantation in men with Peyronie's disease. J Sex Med. 2015;12 Suppl 7:449–454. doi:10.1111/jsm.13001

5. Katlowitz Y, Taniguchi H, Torremade J, Salter CA, Mulhall JP. Extended corporal dilation decreases the need for intraoperative adjuvant maneuvers for residual curvature after inflatable penile implant placement in men with Peyronie's disease. J Sex Med. 2026;23(5):qdag083. doi:10.1093/jsxmed/qdag083

6. Chung E, Blecher G. Perspective: residual penile curvature correction during penile prosthesis implantation by plication in Peyronie's patients. Int J Impot Res. 2023;35(7):643–646. doi:10.1038/s41443-023-00774-6

7. Falcone M, Preto M, Peretti F, et al. The use of collagen fleece to correct residual curvature during inflatable penile prosthesis implantation (PICS technique) in patients with complex Peyronie disease: a multicenter study. J Sex Med. 2023;20(2):229–235. doi:10.1093/jsxmed/qdac003

8. Hatzichristodoulou G. The PICS technique: a novel approach for residual curvature correction during penile prosthesis implantation in patients with severe Peyronie's disease using the collagen fleece TachoSil. J Sex Med. 2018;15(3):416–421. doi:10.1016/j.jsxm.2017.12.012

9. Fernández-Pascual E, Gonzalez-García FJ, Rodríguez-Monsalve M, et al. Surgical technique for complex cases of Peyronie's disease with implantation of penile prosthesis, multiple corporeal incisions, and grafting with collagen fleece. J Sex Med. 2019;16(2):323–332. doi:10.1016/j.jsxm.2018.11.014

10. Farrell MR, Abdelsayed GA, Ziegelmann MJ, Levine LA. A comparison of hemostatic patches versus pericardium allograft for the treatment of complex Peyronie's disease with penile prosthesis and plaque incision. Urology. 2019;129:113–118. doi:10.1016/j.urology.2019.03.008

11. Gamidov S, Shatylko T, Gasanov N, et al. Long-term outcomes of surgery for Peyronie's disease: focus on patient satisfaction. Int J Impot Res. 2021;33(3):332–338. doi:10.1038/s41443-020-0297-6